How the Nation's First COVID-19 Death Went Undetected in San Jose

The revelation last month that the first COVID-19 death in the United States actually occurred on Feb. 6 in Santa Clara County has shifted the understanding of how and when the pandemic moved into California and the rest of the nation.

Patricia Dowd, 57, died at her home in San Jose – not in a hospital, and with no known travel exposure – suggesting the coronavirus spread in Northern California much earlier and wider than initially thought.

These revelations also raise questions about whether Santa Clara County officials could have warned neighboring counties and state officials of possible community spread and pushed for earlier testing of a number of suspicious cases in February and early March.

Dowd was working from her San Jose home, suffering from a flu-like illness, when she died on Feb. 6. Her body was taken to the Santa Clara County Medical Examiner-Coroner, the procedure for sudden, unexpected deaths occurring at home.

Forensic pathologist Dr. Susan Parson performed an autopsy the day after Dowd’s death and, following standard medical practice, collected swabs and tissue samples. Suspecting COVID-19 infection, she kept the case open.

Dowd had not traveled outside the United States for months before her death, according to county public health officials. So even though the San Jose resident died with flu-like symptoms, she did not meet the U.S. Centers for Disease Control and Prevention's testing criteria at the time.

Santa Clara County Health Officer Dr. Sara Cody said at an April 22 press conference that there wasn’t much testing available in January and February.

"We couldn't test everyone," Cody said. "So the medical examiner had these cases where there was a question whether there may have been an infectious cause. And so they just sort of didn't close the cases."

The county’s chief medical examiner, Dr. Michelle Jorden, wrote in an email Thursday that she tested for other viruses that might have contributed to Dowd’s death to rule out other causes before testing for COVID-19. That process took several weeks.

By the time Dowd’s test results came back negative for other viruses, the criteria for COVID-19 testing at the CDC had changed. On Feb. 27, the agency issued new guidance that anyone doctors strongly suspected of having the virus could be tested.

Jorden wrote that because the tissue from Dowd was taken after her death, it could not be analyzed by a local lab. So she sent the sample to the CDC on March 16 and notified her county health department. It had been over a month since Dowd’s death.

“It took the CDC several weeks to provide the results, and those results were released publicly the same day they were received by the Medical Examiner-Coroner” on April 21, Jorden wrote.

Dowd's autopsy officially listed COVID-19 as her cause of death on April 23.

Did the County Alert Others About 3 Suspicious Deaths?

Santa Clara County Public Health officials did not disseminate information about the case to others until the test confirmed COVID-19 on April 21 – more than two months after Dowd’s death.

“The day the results were received from the CDC, they were immediately shared with the state of California Department of Public Health and other partners, and were shared publicly,” an agency spokesperson wrote in a May 1 email.

Santa Clara County announced the news that COVID-19 was confirmed in the tissue samples belonging to three people who died at home: Dowd, and two men who died on Feb. 17 and March 6, respectively. None of them had traveled beforehand, which indicated they caught the virus through community spread.

All three of the COVID-19 deaths Santa Clara County announced in April died in their homes well before March 16, when six Bay Area counties and the city of Berkeley issued shelter-in-place orders to combat community spread of the coronavirus.

“We had been wondering, ‘How will we detect community transmission if we're not testing people who haven't traveled?’ ” Santa Clara County Health Officer Dr. Sara Cody said at a press conference announcing the test results. “And I think this answers the question, in that, ‘We didn't detect community spread.’ ”

But there were strong suspicions in the Medical Examiner’s Office that COVID-19 was causing deaths in the community long before those test results were received.

A March 6 memo obtained by KQED suggests that at least one of the medical examiners in Santa Clara County suspected he had been exposed to multiple decedents with COVID-19 as early as mid-February.

Dr. Joseph O’Hara wrote to a judge to ask that he be excused from testifying in court.

“In the last 2 weeks I have performed examinations on 4 individuals suspected of infection with the COVID-19 virus,” O’Hara wrote, “including one individual who died after being exposed to the virus on the Princess Cruise Line ship.”

O’Hara also stated he was “experiencing symptoms of cough and headache” and couldn’t guarantee he had not been exposed.

The county has not confirmed whether O’Hara was ever quarantined, and attempts to reach him directly were unsuccessful.

When asked about O’Hara’s memo, Jorden responded that she could not provide personal health information about employees, but that staff are following strict guidelines on protecting themselves by using personal protective equipment.

In an earlier interview, Jorden said none of her staff had been “confirmed” to have COVID-19.

Bay Area forensic pathologist Dr. Judy Melinek said Santa Clara County should have sounded an alarm as soon as pathologists suspected COVID-19 caused Dowd’s death.

“If we're not capable of recognizing a potentially transmissible infectious disease when it comes to our door, then we are not doing our job guarding the public health,” Melinek said.

Melinek believes the region may have lost crucial time to isolate people with the virus and implement broad shelter-in-place orders.

“Every day that you don't do contact tracing is a day lost where people who are asymptomatic spreaders or pre-symptomatic spreaders are sharing that virus with other people,” Melinek said. “So every day of delay is potential lives lost.”

Before the COVID-19 pandemic, medical examiners and coroners could send samples freely to a special division of the CDC. Despite repeated inquiries, the CDC has not confirmed whether testing by that division was available in early February when Dowd died.

Still, Melinek was able to rule out COVID-19 in a separate case through CDC testing a couple weeks before Dowd’s death. Melinek examined a decedent in late January who had recently traveled to China and whom she suspected had COVID-19.

Melinek said she contacted CDC’s Infectious Disease Pathology Branch, and that agency staff attended the autopsy and took samples for testing.

“I got an immediate response from them and results within a week or two,” Melinek said.

Dr. Sally Aiken, president of the National Association of Medical Examiners, said forensic pathologists typically can freely submit samples to the special CDC lab for testing that’s not available in other facilities.

“They do immuno-testing for a number of pathogens and unusual pathogens and they provide advice,” Aiken said. “That is available to forensic pathologists, medical examiners and coroners during normal times. And as far as COVID-19 testing, I'm not sure what their limitations were.”

“There was just a major breakdown in obvious, necessary communications,” Santa Clara County Supervisor David Cortese said Monday.

Cortese recently criticized the Medical Examiner-Coroner’s Office for not telling the board about a 20% increase in March fatalities, compared to the year before.

“It just seems to me if I'm running that shop and I see those numbers are trending up, that I start collaborating more closely with public health,” Cortese said. “I'd probably go to the Board of Supervisors and the county executive and say, ‘Hey, these numbers are trending up. How can we be helpful and collaborative and useful in this process?' ”

Many of the deaths were still under investigation and were not yet included in official counts. But, Cortese said, during a pandemic even provisional death data is critical to relay.

“It's important that what you can say, you know,” Cortese said. “But it's also important to say what you don't know, and what is sort of pending, unverified information out there to give people a better handle on what's really going on.”

Melinek believes, if nothing else, that Santa Clara County had a duty to alert forensic pathologists in other offices about these early suspected cases.

“As front-line workers in the death industry, whether we're forensic pathologists or people who work in mortuaries, we have not just a professional responsibility, but also an ethical responsibility to notify each other of potentially transmissible infectious diseases,” Melinek said. “Not only because it impacts us when we're doing our work, but more importantly, because it impacts the public at large.”

Jorden has not responded to questions about why she did not immediately flag Dowd’s and other early cases publicly.

Aiken said pathologists can share that kind of information via a list-serve maintained by professional organizations for medical examiners.

In addition, she said, “Most of us would share that – if not all of us – with public health officials.”

However, Aiken said the awareness of COVID-19 was just beginning in early February.

“They probably did really well to find these cases and get them to the Centers for Disease Control for testing, actually,” Aiken said. “I think they were pretty proactive doing that.”

Narrow Testing Skewed COVID-19 Death Data Statewide

Dr. Scott Morrow, the health officer for neighboring San Mateo County, wrote in an email last week that he wasn’t surprised when he learned of Dowd’s death in news reports.

“I told my colleagues in mid-January that it was likely spreading under our noses,” Morrow wrote. “Without testing we were flying blind, and we continue to fly pretty blind.”

Morrow called the lack of adequate COVID-19 testing “one of the fundamental missteps our country took and continues to take.”

The lack of adequate testing is no fault of Santa Clara County – and was still a factor at the end of March for medical examiners and coroners for some of California's most populous counties. Alameda, Los Angeles, San Francisco, San Mateo and Santa Clara counties were only testing decedents who were known to be symptomatic before they died.

“It’s not that we're having tests fall off the shelves,” Los Angeles County Medical Examiner-Coroner Dr. Jonathan Lucas said in a phone interview in late March. “We're doing a reasonable sort of screening, where, if somebody has symptoms, if they have had a fever in the days before they passed away, we're erring on the side of getting that test.”

Lucas feared that COVID-19 infections may not be detected in all cases where the disease was a contributing factor in someone’s death.

“It's plausible right now, given the shortage of tests, that if somebody died and they didn't have any symptoms whatsoever – nobody brings it up – but maybe they were simply asymptomatic and had the virus, we might not test them,” he said.

The day Santa Clara County announced the news of Dowd’s death, Gov. Gavin Newsom said he had asked other counties to review deaths dating back to December.

“I imagine subsequent announcements that may be made by similar efforts all across the state of California,” Newsom said. The governor’s office deferred questions about when and to whom this directive was sent.

It’s up to counties to submit any changes to the cause of death to the state Department of Public Health, which would recategorize deaths attributed to COVID-19 so they are counted in state totals and shared with the CDC and the National Center for Health Statistics.

A number of medical examiners and coroners contacted by KQED and NPR were not immediately aware of the governor’s directive, but a spokeswoman for the Orange County Sheriff Coroner’s office said protocols are being put in place to review deaths.

Dr. Jorden, the Santa Clara County medical examiner, has continued to identify additional early COVID-19 deaths.

In a letter to the county Board of Supervisors last month, Jorden stated her office had identified 29 people who died with flu-like symptoms and that subsequent tests had confirmed nine of the decedents had the virus, including Dowd.

In some cases, efforts to determine whether COVID-19 caused or contributed to the person’s death were ongoing and were not included in county death totals.

Jorden’s office is continuing to review cases back to Dec 1, 2019, to identify any that warrant further testing.